Laserfiche WebLink
STATE OF CALIFORNIr WATER RESOURCES CONTROL BOARD <br /> FORM IA': V �o <br /> UNDERGROUND STORAGE TANK PROGRAM Z <br /> SI FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m< 10 <br /> [J COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED SITE F"+ <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) C 4 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> S /} SA i e�rmS <br /> ADDRESS NEAREST CROSS STREET ✓Boil iMlcale ❑ PARTNERSHIP ❑ STATEAGENC/ <br /> I I I� ❑ TION ❑ WCAL-AGENCY ❑ FEDERALAGENCY <br /> (/t` DMDUAL ❑ CWNtt AGI <br /> CITY NAME STATE ZIP CODE SITE PHONE It WITH AREA CODE <br /> r a CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRI ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID it <br /> 1 <br /> RESERVATION or ❑ X of TANK'X <br /> 1 GAS STATION 3 FARM 5 OTHER TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> aoq 535— /o7 <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> Sa/A-11-e- <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1(BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ IL ❑ 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY X JURISDICTION X AGENCY X FACILITY ID X X of TANKS at SITE <br /> 00 � � � 000 l <br /> CURRENT LOCAL AGENCY FACILITY IDN_ APPROVED BY NAME PHONE X WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRI SUPERVISOR-DISTRICT CODE BUSINESS`SNG PUN ❑ DATE FILE <br /> 3 <br /> CHECK X PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> SII .I THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1(OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> \vN- FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />